Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Comportamiento en la alimentación y actividad física de preescolares al finalizar un proyecto de promoción de hábitos saludables

Antecedentes: En la etapa preescolar el personal docente y/o los cuidadores formales desempeñan una labor importante como promotores de salud, lo cual tendrá un impacto a corto y largo plazo. Objetivo General: Identificar el comportamiento de alimentación y de actividad física de los preescolares al finalizar un proyecto de intervención de promoción de hábitos saludables en los Centros Infantiles de Desarrollo del Municipio de Cuenca (CDIs). Metodología: Se realizó un estudio mixto cuali-cuantitativo. Resultado: Se observó que el comportamiento alimentario de los niños depende del control que tenga el educador, siendo diferente en cada CDIs, en algunos los niños comen más relajados mientras que en otros gritan, golpean las cosas, etc. El personal de alimentación indica que tienen una organización similar en todos los CDIs, sin embargo, los menús son alterados por diferentes causas, trayendo esto beneficios y desventajas. Los educadores comentario que dentro del material de nutrición preferido para trabajar con los niños fueron los cuentos y las réplicas de alimentos. Por otra parte, el análisis de los menús mostró una calidad ACEPTABLE con el cumplimiento del 59%. Conclusiones: La mayoría de los preescolares consumen tres tiempos de comida en los CDIs, se observó que la actitud y hábitos en la mesa por parte de los educadores influencian directamente en el comportamiento alimentario de los niños al momento de comer. Por lo que es de suma importancia vigilar todos los aspectos e ir corrigiendo los factores que influyen en el comportamiento alimentario de los niñosBackground: In the preschool stage, the teaching staff and / or the formal caregivers play an important role as health promoters, which will have a short and long term impact. General Objective: To identify the feeding and physical activity behavior of the preschool children at the end of an intervention project to promote healthy habits in the Infantile Development Centers of the Municipality of Cuenca (CDIs). Methodology: A quali-quantitative mixed study was carried out. The qualitative approach was carried out through non-participatory observations to children and to the educators during the days of attendance of the children to the CDIs. In addition, structured interviews were conducted with the food service staff of the CDIs to learn how the children's menu is prepared once a training course within the intervention project has been completed. Structured interviews were also conducted with educators to identify the most useful ludic and audiovisual material to teach children eating habits and physical activity. The quantitative study was carried out through the analysis of the quality of the menu eaten by children in the CDIs. For this study, a validated questionnaire was applied. Result: It was observed that the children's eating behavior depends on the control that the educator has, and it is different in each CDI; so, in some CDIs the children eat in a more relaxed way while in others they scream, hit things, etc. The food staff indicates that they have a similar organization in all CDIs, however, menus are altered for different reasons; this fact brings benefits and disadvantages. The teachers commented that stories and food replicas were within the preferred nutrition material to work with children. On the other hand, the analysis of the menus showed an ACCEPTABLE quality, with the fulfillment of 59%. Conclusions: The majority of preschoolers eat three times of food in the CDIs. In addition, it was observed that the attitude and habits that the educators have at the table influence directly on the feeding behavior of the children at the time of eating. Consequently, it is very important to monitor all aspects and to correct the factors that influence the children's eating behaviorLicenciado en Nutrición y DietéticaCuenc